Rasanga Liyanage

Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.

Rasanga is the Advanced Trainee in Sexual Health at Short Street Centre Sexual Health Clinic (St George Hospital) in Kogarah, NSW. She is a Sexual Health Physician from Sri Lanka with over 9 years’ experience and will be presenting her latest research on ‘nPEP knowledge among MSM’ at EACS 2015.

The new EACS guidelines give recommendation for treatment of asymptomatic primary HIV infection (PHI) even when CD4 count is >350. There is strong recommendation to treat if severe or prolonged symptoms, neurological disease, Age>50yrs and if CD4 <350. A French study (ANRS PRIMO cohort) showed rapid viral suppression in 327 patients treated within 1 month of diagnosis of primary infection (91.4% were symptomatic). Median CD4 count was 450. There were 2 cases of remission when treatment was interrupted in the ANRS OPTIPRIM study. The EACS guideline has recommended a regime including PI/r if resistance testing results are not available. Evidence is mostly derived from symptomatic patients and evidence on long term clinical benefits is lacking. The rapid suppression of viral load by Integrate inhibitors was discussed but has not been included in the guideline.

Findings of the Phase 11a Proof of Concept Study for Second generation maturation inhibitor 176 was presented today. The mechanism of action of this drug is it stops the last step of protease cleavage during maturation. In vitro it showed better results than the first generation maturation inhibitors. 10 day monotherapy showed potent antiviral activity for both subtype B and C and it was generally well tolerated. There were no serious adverse events or discontinuations due to adverse events. A phase 11b global study is underway and looks promising. However in vitro resistance data is still being analysed.

A population pharmacokinetic model for a long acting injectable nanosuspension of Rilpivirine for IM injection was presented. The model was used to describe the absorption and disposition of RPV after IMI. The simulations were used to select different dosing regimens for further clinical evaluation. A cohort study showed that 73% of people wanted to use a long acting formulation. Long acting formulations are Cabotegravir 800mg 3 monthly and Rilpivirine 1200mg monthly. Phase 2 trials are underway. However with long acting formulations the risk is that if they miss a dose they can have prolonged periods of low drug levels posing a risk for resistance. They are more likely to be given to people who are less adherent in the first place. However it could be useful in adolescents who may find it harder to take a daily pill.

The Pre congress workshop was aimed at junior specialists and professionals in training and followed a theme of challenging case presentations followed by an overview of the topic by an expert. Women living with HIV seems to be a problem area in London mainly in black African backgrounds. The topic covered was contraception and take home messages were that women tend to go to their GP for contraceptive issues and tend not to disclose their HIV status and end up getting a contraceptive method which interacts with her ART.

There seems to be trend of prescribing Truimeq for women of childbearing age despite the fact that there is no data on teratogenicity of Dolutegravir, in case they have an unplanned pregnancy. Generally regimes are unchanged if they do fall pregnant mainly because by the time the pregnancy is discovered it is usually past 6 weeks. A study is currently underway in African pregnant women on Dolutegravir looking at teratogenicity and so far there have been no reports.

Caesarean section rates seem to be still high in regional centres despite viral suppression to undetectable levels. This is party accounted for the number of women with a previous section but they are hoping it will go down in future. Considering the poor compliance of women coming back for contraception at 6 weeks post partum, intracaesarian IUD insertion had been effective both in the USA and Africa with expulsion and infection being rare and may be used for an occasional poorly compliant woman.

The session on 'Chem sex' was quite interesting as I learnt a lot of new jargon relating to sex and drugs. There is about a 15% rise in IVDU among MSM in UK in the last decade giving rise to the risk of spread of HIV, HBV, HCV, HDV, and of course STI's. Slamming is another word used for using psychoactive substances in a party or sex settings. A qualitative study done in Paris showed that men using these drugs were unaware of their HIV and HCV status rates being as high as 40-60%.

When considering the amount of MSM turning up at the clinic on Monday afternoon for PEP after a 'wild weekend', I think that chemsex would be a potential problem in Sydney and other major cities in Australia very soon. Repeated HCV infections are a major problem in this group.

For both contraception and chemsex, a most valuable site is the Liverpool drug interactions website. www.hiv-druginteractions.org

STI session was quite interesting and increased rates of gonorrhoea, Chlamydia and syphilis were universal all across Europe in the last couple of years.

Funny fact - In the olden days gonorrhoea was treated by hitting the penis with a bible! :)